Controversy surrounds ‘guilt inducing’ Veterans Affairs booklet on end-of-life issues

Tim Towey / Dr. Robert Pearlman
Tim Towey / Dr. Robert Pearlman


A booklet from the U.S. Department of Veterans Affairs (VA) on end-of-life issues asks its veterans to consider under what circumstances their life might not be “worth living.” One critic says the booklet is “guilt inducing” and sends a “hurry-up-and-die” message, while a U.S. Senator has called for hearings on its contents.

The booklet “Your Life, Your Choices” says it is intended to help plan for future medical decisions and for the preparation of a personalized living will.

The 52-page document includes a checklist asking “What makes my life worth living?” The reader is asked to rate scenarios on the checklist by quality of life.

Statements on the checklist ask the reader to consider his view of a life of severe pain, a life in which he can no longer contribute to his family’s well being, a life in which he cannot control bodily functions, and a life in which he cannot walk or leave the house.

Other statements have the reader consider whether being a “severe” emotional or financial burden on one’s family is a life worth living.

Categories for the statements on the checklist are “difficult, but acceptable,” “worth living, but just barely,” “not worth living,” and “can’t answer now.”

Beneath the checklist, the booklet asks the reader to consider whether a combination of “just barely” livable factors would make his life “not worth living.”

It also asks: “If you checked ‘not worth living,’ does this mean that you would rather die than be kept alive?”

The booklet itself does not explicitly raise the issue of drug- or physician-assisted suicide. However, it asks the reader to consider whether he believes artificial hydration and nutrition are morally obligatory. It also asks the reader to consider whether pain relief is acceptable if it hastens death.

Additionally, the booklet asks the reader to consider his desired treatment in cases where he has severe dementia, has a severe stroke, is permanently comatose, or is terminally ill.

For each situation, it asks whether or for how long the reader would like antibiotics, a feeding tube, dialysis, a mechanical ventilator, and comfort care.

Robert Pearlman, M.D., M.P.H., was listed as the document’s lead author. He is chief of ethics evaluation at the VA’s National Center for Ethics in Health Care.

Jim Towey, a former director of the White House Office of Faith-Based Initiatives under the George W. Bush administration, reported in an August 18 Wall Street Journal opinion piece that Pearlman advocated allowing physician-assisted suicide in 1996 before the U.S. Supreme Court in the decision Vacco v. Quill.

Towey, who is also president of St. Vincent’s College in Pennsylvania and a former volunteer in a Missionaries of Charity AIDS hospice, strongly criticized the VA booklet.

According to Towey, “Your Life, Your Choices” was first published in 1997 and was initially the VA’s preferred document for living wills. Under the George W. Bush administration, after the White House examined the document the VA removed it from use.

Towey characterized parts of the document as describing “guilt inducing” scenarios and promoting a “hurry-up-and-die” message. He also reported that a July 2009 VA document instructed its primary care physicians to raise the issue of advanced care with all VA patients and to refer them to “Your Life, Your Choices.”

In addition, Towey said that a VA expert panel which in 2007-2008 sought to update the “Your Life, Your Choices” booklet did not include any representatives of faith groups or disability rights groups. He said in the new version of the booklet the only organization listed as a resource on advance directives is Compassion and Choices, the suicide advocacy group formerly known as the Hemlock Society.

According to Fox News, on Sunday Sen. Arlen Specter (D-PA) said the document raises “a lot of questions.”

"I think consideration ought to be given right now to suspending it pending hearings,” Specter told Fox News Sunday.

Tammy Duckworth, an injured veteran who is the assistant secretary for the VA, said the document is under revision and its status was reported as such on the VA website. She told Fox News it has not been officially reinstated and described it as “simply a tool” for injured veterans.

CNA accessed a copy of “Your Life, Your Choices” on the website of the U.S. Department of Veterans Affairs this morning, but it was apparently removed from the site later on Monday.

The pamphlet “A Catholic Guide to End-of-Life Decisions,” produced by the National Catholic Bioethics Center, summarizes Catholic end-of-life ethics, saying:

“When death is imminent one may refuse forms of treatment that would only result in a precarious and burdensome prolongation of life. There is a presumption in favor of continuing to provide food and water to the patient, but there is a stage in the dying process when even these may no longer be obligatory because they provide no benefit. Normal care always remains morally obligatory, but refusal of additional treatment when death is imminent is not equivalent to suicide.”

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